Pneumococcal infections, including pneumonia and invasive disease such as bacteremia and meningitis, have been a major source of morbidity and mortality since the beginning of the HIV epidemic, leading many experts to endorse use of pneumococcal vaccine for primary prevention in HIV-infected patients [1]. However, the efficacy of pneumococcal vaccine in this patient population has been debated for many years [2]. In addition, pneumococcal vaccines are serotype-specific, so efficacy will also vary depending on the prevalent serotypes within the community.

Pneumococcal pneumonia and meningitis are leading causes of morbidity and mortality among HIV-infected patients worldwide and treatment is complicated by the increasing incidence of drug-resistant pneumococcal strains [3,4]. The overall incidence of invasive pneumococcal disease was 677 cases per 100,000 person-years in HIV-infected patients [3]. The case fatality rate of invasive disease ranges from 8 percent with pneumococcal bacteremia to 50 percent with meningitis [5,6].

A retrospective study performed in San Francisco, prior to the era of potent antiretroviral therapy (ART), found that the rates of pneumococcal bacteremia were approximately 100-fold greater in HIV-infected patients compared with those who were not infected with HIV [1]. In addition, recurrent invasive pneumococcal disease is common, occurring in up to 25 percent of patients within a year after the initial episode [7].

Risk factors — The most important risk factor for developing pneumococcal infections is the level of immunosuppression [7-10]. In one trial of pneumococcal vaccine efficacy, the vast majority of HIV-infected patients who developed invasive pneumococcal disease had a CD4 count <200 cells/mm3 [11].

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Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on July 22, 2013).

Department of Health and Human Services. Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children. Available at: aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf (Accessed on November 20, 2013).